Home Health & Hospice Week

If additional development requests for claims under medical review get lost in the shuffle at your home health agency, you're letting reimbursement needlessly slip through your fingers.

Failing to send in medical records by the 30-day deadline (denial code 56900) was the number-one reason HHAs saw claims denials from regional home health intermediary Palmetto GBA last October, according to a list of the top 10 denial reasons recently posted to Palmetto's Web site.

Although responding to ADRs on time might seem like a basic activity, there are a number of reasons agencies have trouble complying. HHAs that rely on receiving paper ADRs might not even be aware they have claims under medical review if they're failing to check for the requests online, says consultant Kay Hollers with Austin, TX-based Healthcare Executive Resources.

Or ADRs might be directed to the wrong person at an agency, points out consultant Laura Gramenelles with Simione Consultants in Hamden, CT. By the time requests make it to the right person, agencies could be pushing the 30-day time limit.

The problem could be with HHAs getting responses out the door on time. If ADRs migrate to the bottom of a staffer's workpile while she attends to other issues, the deadline can sneak by. Or if the response has to pass through a battery of eyes before submission, one slow link in the review chain can cause a fatal delay, notes Gramenelles.

Failing to respond to an ADR properly "is the worst reason to lose money," insists Hollers. And it's largely preventable.

HHAs must make ADR processing a priority, Hollers stresses. That includes implementing a fool-proof tracking system for requests that begins with daily online checking for ADRs, Gramenelles advises. If the claim is in status SB6001 on the Direct Data Entry (DDE) system, you must send in supporting records, Palmetto directs.

Agencies that feel they send the responses on time but don't get credit for them should use a mail delivery method that requires proof of receipt from the intermediary, Hollers recommends. Providers should return the medical records to the address on the ADR, Palmetto instructs.

And providers should keep copies of everything they send in, so they can re-send materials quickly if they become lost, Hollers adds.

Another top denial reason found by Palmetto was upcoding (denial code 5DOWN). In those cases, "the home health agency has billed services at a higher payment level than the medical documentation submitted supports, as a result reimbursement has been adjusted to a lower payment level," Palmetto explains.

The main culprit here is a discrepancy between the OASIS assessment and the chart documentation, Gramenelles says. Medical reviewers pore over both documents to assure consistency under the prospective payment system.

Two hot spots for this problem are trauma diagnosis codes 800 through 999 and physical therapy, Hollers finds. HHAs should use trauma diagnosis codes, which increase reimbursement, only when there's been a traumatic injury from an accident or violence, the Centers for Medicare & Medicaid Services explains in its diagnosis coding guidance at http://cms.hhs.gov/medlearn/refhha.asp. And the significant reimbursement impact of furnishing 10 or more therapy visits draws scrutiny to those services.

Therapy also is a trigger for medical necessity determinations resulting in a partial denial (5H164), Hollers says. Denials she has seen have involved claims with both physical and occupational therapy and have disallowed the OT visits as a duplication of services, usually knocking the patient under the 10-visit threshold and into a no-therapy payment category.

Skilled observation is another red flag, and denial of the service "either due to no longer a reasonable potential for change in condition, or sufficient time has been allowed for teaching or observation of response to treatment" (5A041) made the top-10 list, Palmetto says.

Intermediaries often use this denial for re-certifications, Gramenelles explains. HHAs should ask some crucial questions about skilled observation patients at recert, including whether and how long the patient's condition has been stable and if the diagnosis is appropriate for the service and the patient. Putting skilled observation patients up for case conferencing upon recert is a good way to ensure those questions get asked, she counsels.

The HIM 11 indicates a medically unstable condition requiring skilled observation would normally last no longer than 21 days, says Hollers. While HHAs can justify that patients will need it beyond that timeframe, they must clearly and comprehensively document the need for that service in the chart, she advises. Agencies should "submit documentation of any changes in condition that warrant skilled care," Palmetto adds.

Other denial reasons rounding out the top-10 list include a full denial for documentation not supporting medical necessity (5D164), no physician's orders resulting in a partial (5H161) or full (5D161) denial, unspecified reasons (5T009), services not documented (5H169) and dependent services denied because the qualifying medical service was denied (5ADSD).